In the United States, health care spend has grown at a rate faster than the gross domestic product.
In 2016, according to the federal government, America’s total medical costs hit a new record of $3.3 trillion. The Agency for Healthcare Research and Quality estimates that the direct medical costs for cancer in the US in 2015 were $80.2 billion.1 There is an inevitable pressure on health plans to reduce costs while ensuring quality care.
Cancer care has become increasingly complex. It has become a challenge for patients to receive care consistent with evidence-based guidelines, while ensuring quality care is prescribed for all.
Factors Leading to Inappropriate Care and Reimbursement
Escalating complexity of care. The science of medicine has advanced far beyond what an individual practitioner can process, track and know without some sort of advanced systems support.
"For years, the oncology community has known that the practicing oncologist has too many details to track for major clinical decisions, but support systems are not yet ingrained in clinical care," says Dr. William A. Flood, Eviti’s Chief Medical Officer.
As science advances, the number of potential treatment options multiplies. The expansion of data prompts increasingly complex medical decision-making parameters, including functional and anatomical diagnostics, proteomics, and genetics, in addition to symptom considerations. The explosion of new treatment modalities makes it increasingly difficult for oncologists to stay up to date. On top of compounding treatment options, providers must consider treatment costs and value. Without systems support at the point of clinical decision-making, there is a lag between establishment of new therapies and their widespread, appropriate use.
Increasing number of newly-diagnosed cancer patients. An important and growing demographic in cancer is the number of elderly Americans.2 The incidence of cancer increases in elderly populations, and exponentially into the over-85 segment. As a result, the number of new cancer patients each year will increase to almost 2 million by 2020.
Oncologists shortage. A study for The American Society of Clinical Oncology (ASCO) by the Association of American Medical Colleges (AAMC) projects a significant shortage of medical and gynecologic oncologists in the United States by 2020.3
Perverse incentives. As payers mandate that oncology treatment be pre-authorized, physician incomes are tied to drug and procedure costs and utilization, and incentives may not reflect the highest quality treatments offering the most value.
With rising costs in cancer care, increased patient load and imminent shortage in oncologists, it is vital that cancer patients receive treatment based upon evidence-based guidelines. Systems support at the moment of clinical prescribing will help physicians deal with the growth in treatment complexity, thereby reducing the incidence of inappropriate care and ensuring the prescription of high-quality care. In addition, systems support integrated with automated pre-authorization at the point of care will eliminate payment for inappropriate care and reduce overall cancer treatment costs for payers.
Qualities of an Effective Solution
Scalability. To realize cost savings, a solution must be fully-scalable and transform how medical care is prescribed and paid for through the selection of quality care at the moment of clinical prescribing. It should combine the power of electronic platforms, clinical expertise, and nationally-accepted treatment guidelines to diminish variability in care, while supporting greater coordination between medical practices and payers.
Comprehensive Source Data. An effective solution will provide physicians with a single resource of all up-to-date, evidence-based standards and clinical trials to allow the provider to make the most informed decision with the patient. It will consider all factors needed to make the most appropriate treatment decision, including costs, toxicities, and observed outcomes.
Transparency. Linking an evidence-based cancer treatment library with payer plan language and automated, web-based pre-authorization will provide payers with visibility into the care that is prescribed and ensure they are paying for appropriate care. When members receive the right care up front, wasteful spending is reduced, representing a cost savings. For the payer, the solution must provide transparency and predictability, connecting the provider and the payer in real time at the moment of prescribing, before treatment ever begins.
Alignment. Effective systems support will eliminate inappropriate treatment (system failure) through the application of nationally-accepted treatment standards at the moment of clinical prescribing, ensuring that compliance takes place at the front-end as opposed to back-end review after treatment has begun. It will also obtain physician collaboration through a comprehensive set of evidence-based treatment regimens that allow physicians to practice medicine, and will offer high-quality clinical trials, including systematized intelligence to distinguish between routine costs of care and experimental costs to help meet State and Federal health law coverage mandates. Most importantly, it connects and delivers value to all parties in the care process: patients, physicians, and payers - avoiding resource strain caused by appeals and denials.
Eviti Connect electronically connects health plans and oncology practices for the authorization of oncology treatments in real-time, validating cancer treatment decisions with evidence-based medicine before treatment begins. The automated process reduces the administrative time involved in obtaining and providing authorizations at the drug level and assures appropriate reimbursement at the regimen level, aligning all parties around value-based oncological care.
Learn more about how you can enable high quality oncology care by aligning the needs of health plans, providers, and patients before treatment begins. Click here to download the brochure.